Biliopancreatic Diversion/duodenal Switch Research Articles

Bariatric Surgery in Patients with Previous Cardiac Revascularization: Review of Literature.

Background: The diet and physical activity of the world's population determine the increase in the number of bariatric surgeries. The most common types of bariatric surgery are laparoscopic sleeve gastrectomy (LSG) and Roux-Y gastric bypass (RYGB). Surgical interventions are carried out in patients with numerous comorbidities, among which the most common are cardiovascular diseases. The aim of the present study was to review the literature regarding the safety and results of surgical treatment in patients with cardiac revascularization prior to surgery. Methods: We performed an online search in Pubmed in September 2023 to identify articles that reported cardiac revascularization prior to bariatric surgery. The extracted information included details of the working method, number of patients, types of cardiovascular disease-heart failure (HF) and cardiac artery disease (CAD), types of revascularization-coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI) or both CABG + PCI, demographic data (age, gender, race), clinical characteristics (body mass index-BMI, smoking status), comorbidities (diabetes mellitus, hypertension, prior myocardial infarction), postoperative complications, and postoperative results. Results: A total of 171 records were identified by the initial search, and 165 papers were excluded after applying the exclusion criteria (types of cardiovascular disease, types of revascularization, and demographic data). We evaluated a group of 9479 patients of which 730 had HF, 2621 CAD, and 1426 underwent prior cardiac revascularization. The analysis of the demographic data showed an average age of 55.5 years and a fluctuation of the male gender between 39% and 71.1%, and the female gender between 28.9% and 61%. The main types of bariatric interventions were RYGB (3659 cases) and LSG (659 cases), to which adjustable gastric band (AGB) and bilio-pancreatic diversion-duodenal switch (BPD-DS) were added. Among the most postprocedural complications were ST-segment elevation myocardial infarction (2 patients), gastro-intestinal bleeding (51 cases), pulmonary embolism (1 patient), arrhythmia (3 patients) and pacemaker insertion (1 patient). The recorded postoperative mortality rate was 0.42% (6 cases). Conclusions: Bariatric surgery remains safe in patients with cardiac revascularization. These finding need to be confirmed in more large-scale randomized trials.

The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic.

Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.

Discontinuation of blood pressure–lowering, glucose–lowering, and lipid–lowering medications after bariatric surgery in patients with morbid obesity: a nationwide cohort study in South Korea

BackgroundLimited evidence exists on the patterns of medication use for hypertension, diabetes mellitus (DM), and dyslipidemia after bariatric surgery among Asian patients. ObjectivesTo investigate the patterns in the use of blood pressure–lowering, glucose-lowering, and lipid-lowering medications following BS in Korean patients with morbid obesity. SettingThis study is a retrospective cohort study using the Health Insurance Review and Assignment claims database of South Korea (from 2019 to 2021). MethodsWe included patients who underwent BS between 2019 and 2020 in South Korea. We evaluated the treatment patterns of blood pressure–lowering, glucose-lowering, and lipid-lowering medications at 3-month intervals for 1-year following BS, including medication use, individual medication classes, and the number of medications prescribed. Furthermore, we estimated remission rates for each disorder based on patient characteristics by defining patients who discontinued their medications for at least 2 consecutive quarters as remission. ResultsA total of 3810 patients were included in this study. For 1-year following BS, a marked decrease in the number of patients using blood pressure–lowering, glucose-lowering, and lipid-lowering medications was observed. The most remarkable decrease occurred in glucose-lowering medications, which decreased by approximately −75.1% compared with that at baseline. This tendency was consistently observed when analyzing both the number of medications prescribed and the specific medication classes. Regarding remission rates, patients who were female, younger, and received the biliopancreatic diversion-duodenal switch as their BS showed a relatively higher incidence of remission than other groups. ConclusionsBS was associated with a decrease in the use of medications for hypertension, diabetes mellitus (DM), and dyslipidemia.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database.

For patients with super obesity (BMI > 50kg/m2), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS. The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18years of age, BMI > 50kg/m2, and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes. There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m2, p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019). Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

Obesity years: clinical variation by age pre/post biliopancreatic diversion/duodenal switch (BPD/DS)

Objective: To identify clinical variation by age, pre/post BPD/DS. Methods: 1673 BPD/DS patients from the Surgical Review Corporation’s BOLD database were analyzed retrospectively by age: &lt;30(177), 30-40(456), 40-50(486), 50-60(407), 60-70(138), &gt;70(9). Data: Demographics, BMI and 33 obesity co-morbidities. Statistics: ANOVA and General Linear Models including pre- and post-operative data modified for binomial distribution of dichotomous variables. Results: Pre-op BMI varied inversely by age and continued through to 12 months post operatively. Gout varied directly and tobacco abuse inversely by age at baseline. The incidence of 12 of the 33 obesity-co-morbidities increased directly with age up to 12 months post operatively. In &gt;60 patients, angina, MS pain, LEE and SUI increased from baseline after undergoing BPD/DS. Conclusion: Despite lower pre-operative and 12-month BMI in older BPD/DS patients, baseline co-morbidities varied directly with age, and post-operative resolution of 12 weight-related problems was inversely proportional to age. Only diabetes resolved better among older patients. These findings suggest the concept of “obesity years”, wherein patients carrying obesity the longest accumulate more co-morbidities and resolve them less.

Sleeve gastrectomy and its modifications

: Initially sleeve gastrectomy (SG) was performed as an open procedure in 1988, known as Hess and Marceau’s technique, which is actually the first stage of the bilio-pancreatic diversion-duodenal switch (BPD-DS). It was proposed in 1993 as a single weight-loss procedure defined by Johnston, later known as operation Magenstrasse and Mill. In 1999 Gagner was the first to describe laparoscopic SG technique. Therefore SG became popular and one of the most common bariatric surgery procedure in the world. The method has many technical differences. Unfortunately, there is still no strict standardization of the method. With the development of technology, robotic surgery has taken its place in bariatric surgery field. A lot of new studies on robotic SG (RSG) have recently been published. Also there are several technical conflict, such as distance from the pylorus, resection of greater curvature, size of the antrum, use of bougie, fundus resection, whether or not reinforce the staple line, identification and repair of the hiatus. There are also some contraindications for SG. Barrett’s esophagus is a one of them. These variations in the technique affect the complications and effectiveness of surgery. In this study, we aimed to discuss the development and modifications of SG steps of with the current literature review.

A Population-Based Study of Early Postoperative Outcomes in Patients with Heart Failure Undergoing Bariatric Surgery.

Weight loss following bariatric surgery can improve cardiac function among patients with heart failure (HF). However, perioperative morbidity of bariatric surgery has not been evaluated in patients with HF. The National Surgical Quality Improvement Project (NSQIP) database for 2006-2014 was queried to identify patients undergoing adjustable gastric band, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion-duodenal switch. Patients with HF were propensity matched to a control group without HF (1:5). Univariate analyses evaluated differences in complications, and multivariate analysis was completed to predict all-cause morbidity. There were 237 patients identified with HF (mean age 52.8years, 59.9% female, mean body mass index 50.6kg/m2) matched to 1185 controls without HF who underwent bariatric surgery. Preoperatively, patients with HF were more likely to be taking antihypertensive medication and have undergone prior percutaneous cardiac intervention and cardiac surgery. There was no difference in operative time, surgical site infections, acute renal failure, re-intubation, or myocardial infarction. HF was associated with increased likelihood of length of stay more than 7days, likelihood to remain ventilated > 48h, venous thromboembolism, and reoperation. For patients with HF, the adjusted odds ratio for all-cause morbidity was 2.09 (1.32-3.22). The NSQIP definition of HF, which includes recent hospitalization for HF exacerbation or new HF diagnosis 30days prior to surgery, predicts a more than two-fold increase in odds of morbidity following bariatric surgery. This must be balanced with the longer-term potential benefits of weight loss and associated improvement in cardiac function in this population.

Hypocalcemia After Bariatric Surgery: Prevalence and Associated Risk Factors.

The reported prevalence of hypocalcemia after bariatric surgery ranges from 1% after Roux-en-Y gastric bypass (RYGB) to 25% after bilio-pancreatic diversion-duodenal switch (BPD-DS). We aimed to define the prevalence of post-operative hypocalcemia and identify clinical predisposing factors. The study was conducted in an Academic Medical Center, USA. Retrospective analysis of all patients undergoing bariatric surgery from May 2008 to December 2014 at Mayo Clinic Rochester, Minnesota was performed. Patients with revision surgeries were excluded. Hypocalcemia was defined as the lowest recorded serum calcium occurring at least 2weeks post-operatively. Nine hundred ninety-nine patients fulfilled the criteria above. After correction for serum albumin concentration, 36 patients had serum calcium ≤8.9mg/dl. Mean serum calcium was 8.1±0.6mg/dl. The prevalence was 1.9% in the RYGB group, 9.3% in the sleeve gastrectomy (SG) group, and 10% in the BPD-DS group. In all three surgical types, patients with hypocalcemia had significantly lower serum albumin and serum 25 (OH) vitamin D concentrations when compared to their normocalcemic counterparts (P<0.01). The presence of renal insufficiency and vitamin D deficiency was associated with the highest risk of developing hypocalcemia after surgery [OR 16.8 (6.45-47.7) and 7.1(2.9-17.3), respectively]. Pre-operative renal insufficiency increased the odds of developing hypocalcemia by 20-fold. In our series, hypocalcemia was identified in 3.6% of patients undergoing all bariatric surgery. Patients who are predisposed to developing post-operative hypocalcemia, such as those with pre-operative renal impairment, or post-operative vitamin D deficiency and renal insufficiency, may benefit from increased surveillance and prevention strategies.

Prospectively validated preoperative prediction of weight and co-morbidity resolution in individual patients comparing five bariatric operations

BackgroundNo method preoperatively predicts the postoperative bariatric surgery outcomes in individual patients. Decisions for or against surgery and operation choice remain subjective. Only 1% of qualifying patients embrace bariatric surgery. ObjectiveTo predict preoperatively and validate prospectively the weight and co-morbidity resolution in individual patients after open Roux-en-Y gastric bypass (RYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (SG), and biliopancreatic diversion/duodenal switch (BPD/DS). SettingSurgical Review Corporation BOLD database, 2007–2010. MethodsA total of 166,601 patients who had undergone RYGB (n = 5389), LRYGB (n = 83,059), LAGB (n = 67,514), SG (n = 8966), or BPD/DS (n = 1673) were randomized into modeling (n = 124,053) and validation (n = 42,548) groups. From preoperative data, multivariate linear and logistic regression predicted weight and co-morbidities at 2, 6, 12, 18, and 24 months postoperatively. Model fit was examined by R2 and receiver operating characteristic/area under the curve and predicted versus observed results via Pearson correlation coefficient and sensitivity/specificity. ResultsFollow-up at 2/24 months was 120,909/11,014 for the modeling group and 41,528/3703 for validation. Weight models’ R2 was .910, .813, .725, .638, and .613 at 2, 6, 12, 18, and 24 months, respectively. The categorical receiver operating characteristic/area under the curve was .617 to .949 for 24-month predictions. Pearson continuous coefficients were .969 and .811 at 2 and 24 months, respectively. The median 24-month sensitivity and specificity of co-morbidity resolution were 79.2% and 97.42%, respectively. ConclusionsProspectively validated preoperative models predict, in individual patients, weight and obesity co-morbidities 2 years in advance for RYGB, LRYGB, LAGB, SG, and BPD/DS. This advance knowledge facilitates choosing the operation that is best for each individual and may encourage more patients to choose bariatric surgery.

Revision of Roux-En-Y Gastric Bypass for Weight Regain: a Systematic Review of Techniques and Outcomes.

Weight regain has led to an increase in revision of Roux-en-Y gastric bypass (RYGB) surgeries. There is no standardized approach to revisional surgery after failed RYGB. We performed an exhaustive literature search to elucidate surgical revision options. Our objective was to evaluate outcomes and complications of various methods of revision after RYGB to identify the option with the best outcomes for failed primary RYGB. A systematic literature search was conducted using the following search tools and databases: PubMed, Google Scholar, Cochrane Clinical Trials Database, Cochrane Review Database, EMBASE, and Allied and Complementary Medicine to identify all relevant studies describing revision after failed RYGB. Inclusion criteria comprised of revisional surgery for weight gain after RYGB. Of the 1200 articles found, only 799 were selected for our study. Of the 799, 24 studies, with a total of 866 patients, were included for a systematic review. Of the 24 studies, 5 were conversion to Distal Roux-en-y gastric bypass (DRYGB), 5 were revision of gastric pouch and anastomosis, 6 were revision with gastric band, 2 were revision to biliopancreatic diversion/duodenal switch (BPD/DS), and 6 were revision to endoluminal procedures (i.e., stomaphyx). Mean percent excess body mass index loss (%EBMIL) after revision up to 1 and 3-year follow-up for BPD/DS was 63.7 and 76%, DRYGB was 54 and 52.2%, gastric banding revision 47.6 and 47.3%, gastric pouch/anastomosis revision 43.3 and 14%, and endoluminal procedures at 32.1%, respectively. Gastric pouch/anastomosis revision resulted in the lowest major complication rate at 3.5% and DRYGB with the highest at 11.9% when compared to the other revisional procedures. The mortality rate was 0.6% which only occurred in the DRYGB group. All 866 patients in the 24 studies reported significant early initial weight loss after revision for failed RYGB. However, of the five surgical revision options considered, BPD/DS, DRYGB, and gastric banding resulted in sustained weight loss, with acceptable complication rate.

Single Anastomosis Gastro Ileal Bypass with Pyloric and Gastric Plication (SAGI PGP): A New Innovative Bariatric Operation

Objectives: Objective is to analyze the operation results of 270 patients in 2013, 2014 and 2015. Setting: Soran Private Hospital/Department of general &laparoscopic surgery/ErbilIraq. Methods: The mean BMI of patients is 43.5 kg/m2 with female patient were 165 and male patients were 115. Type 2 DM was presenting in 68 patients. Hypertension in 48 Hypercholesterolemia in 104, Hypertriglyceridemia in 178 and sleep apnea in 20, polycystic ovarian syndrome in 34 patients. Case study was possible for 240 patients in the 1st year post operation and 200 patients for the 2nd year and 130 in the 3rd year. Results: EWL is above 90% at first year, 85% at year 2. All diabetic patients return to normal blood sugar level usually at the first month with no need for any kind of anti-diabetic medication. Conclusion: SAGI PGP is a novel operation with the least complication that can happen in any other type of bariatric surgeries and the best EWL that can be expected. This technique is combination of single anastmosis gastroileostomy with gastric and pyloric placation. It is a simplified version of biliopancreatic diversion duodenal switch. SAGI PGP is a new combination of bariatric techniques which introduce gastric placation the new simple but yet very effective diversion component which is replacing the duodenal switch and other difficult diversion modalities. Gastric placation is also considered a new territory in bariatric operations and it combination with malasorbative component is rarely done so we try to explore this area and to reach the best results for our patients.

Iron Deficiency Anemia after Bariatric Surgery

As obesity and bariatric surgery rates continue to increase, anemia will become noticeable problems for this patient population. Preoperative assessment of patients should include a complete hematological work-up, including measurement of iron stores, vitamin B12, and folate. Iron deficiency after bariatric surgery results from both malabsorption and maldigestion of dietary iron. Bariatric bypass surgeries, namely Roux-en-Y gastric bypass (RYGB) and Biliopancreatic diversion-duodenal switch (BPD-DS), exacerbate this problem. Iron deficiency is identified in preoperative and postoperative bariatric patients, particularly in premenstrual women. Decreased acid production in the small gastric pouch impedes the solubilization of ferric iron and ultimately absorption of the reduced form, ferrous iron, in the duodenum. Postoperative changes in eating habits and food preferences may also contribute to development of iron deficiency after RYGB. Menstruating women are at high risk for iron deficiency and anemia after bypass surgery. Postoperatively, oral iron supplementation in addition to a multivitamin should be prescribed for RYGB patients. Pregnant women who have undergone bariatric surgery may also be at high risk of developing iron deficiency, and these patients may require aggressive oral iron supplementation. Once iron deficiency has developed, however, it may show refractory to treatment. In some cases, intravenous iron, blood transfusions, and surgical interventions to stop sources of bleeding may be required. Bariatric surgery patients call for lifelong follow-up of hematological and iron parameters, since iron deficiency and anemia may develop years after surgery.

Metabolic/Bariatric Surgery Worldwide 2011

Metabolic/bariatric procedures for the treatment of morbid obesity, as well as for type 2 diabetes, are among the most commonly performed gastrointestinal operations today, justifying periodic assessment of the numerical status of metabolic/bariatric surgery and its relative distribution of procedures. An email questionnaire was sent to the leadership of the 50 nations or national groupings in the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Outcome measurements were numbers of metabolic/bariatric operations and surgeons, types of procedures performed, and trends from 2003 to 2008 to 2011 worldwide and in the regional groupings of Europe, USA/Canada, Latin/South America, and Asia/Pacific. Response rate was 84%. The global total number of procedures in 2011 was 340,768; the global total number of metabolic/bariatric surgeons was 6,705. The most commonly performed procedures were Roux-en-Y gastric bypass (RYGB) 46.6%; sleeve gastrectomy (SG) 27.8%; adjustable gastric banding (AGB) 17.8%; and biliopancreatic diversion/duodenal switch (BPD/DS) 2.2%. The global trends from 2003 to 2008 to 2011 showed a decrease in RYGB: 65.1 to 49.0 to 46.6%; an increase, followed by a steep decline, in AGB: 24.4 to 42.3 to 17.8%; and a marked increase in SG: 0.0 to 5.3 to 27.89%. BPD/DS declined: 6.1 to 4.9 to 2.1%. The trends from the four IFSO regions differed, except for the universal increase in SG. Periodic metabolic/bariatric surgery surveys add to the knowledge and understanding of all physicians caring for morbidly obese patients. The salient message of the 2011 assessment is that SG (0.0% in 2008) has markedly increased in prevalence.

Splenic infarction as a complication of laparoscopic sleeve gastrectomy

Introduction: Laparoscopic sleeve gastrectomy (LSG) as a stand-alone or a first step in the biliopancreatic diversion - duodenal switch (BPD-DS) procedure is frequently the surgery of choice for the 21st century's epidemic of morbid obe- sity. To date, LSG as a relatively new method has few complications reported and analysed. Aim: The article describes splenic infarction, not reported so far, a potentially serious complication of LSG, analyses its causes, and suggests a considerate treatment and follow-up protocol. Material and methods: During the observation period between March and November 2008, 24 LSG patients (20 female and 4 male) were enrolled with mean body mass index of 44 kg/m 2 . All LSG procedures were recorded. Computerized statistical software Statistica 7 StatSoft, Krakow, Poland was used for analysis. Statistical significance was calculated with nonparametric tests (p < 0.05). Results: In 4 patients (17%) splenic infarction was diagnosed intraoperatively. Consecutive angio-CT scan confirmed infarction of the upper splenic pole with 12% to 33% of the splenic pulp affected. Two out of 4 patients had one minor perioperative complication. There were no significant differences between patients. Video analysis excluded possible technical errors. Conclusions: The described analysis suggests short gastric vessels and upper terminal splenic artery branch dissection as possible causative factors of splenic infarction in the course of LSG. We suggest a considerate protocol with abdom- inal cavity inspection at the beginning and end of the procedure, angio-CT scans, prophylactic LMWH, initial broad spectrum intravenous antibiotics, and appropriate follow-up with neither splenectomy nor related immunization.

Fat malabsorption and increased intestinal oxalate absorption are common after roux-en-Y gastric bypass surgery

Hyperoxaluria and increased calcium oxalate stone formation occur after Roux-en-Y gastric bypass (RYGB) surgery for morbid obesity. The etiology of this hyperoxaluria is unknown. We hypothesized that after bariatric surgery, intestinal hyperabsorption of oxalate contributes to increases in plasma oxalate and urinary calcium oxalate supersaturation. We prospectively examined oxalate metabolism in 11 morbidly obese subjects before and 6 and 12 months after RYGB (n = 9) and biliopancreatic diversion-duodenal switch (BPD-DS) (n = 2). We measured 24-hour urinary supersaturations for calcium oxalate, apatite, brushite, uric acid, and sodium urate; fasting plasma oxalate; 72-hour fecal fat; and increases in urine oxalate following an oral oxalate load. Six and 12 months after RYGB, plasma oxalate and urine calcium oxalate supersaturation increased significantly compared with similar measurements obtained before surgery (all P ≤ .02). Fecal fat excretion at 6 and 12 months was increased (P = .026 and .055, 0 vs 6 and 12 months). An increase in urine oxalate excretion after an oral dose of oxalate was observed at 6 and 12 months (all P ≤ .02). Therefore, after bariatric surgery, increases in fecal fat excretion, urinary oxalate excretion after an oral oxalate load, plasma oxalate, and urinary calcium oxalate supersaturation values were observed. Enteric hyperoxaluria is often present in patients after the operations of RYGB and BPD-DS that utilize an element of intestinal malabsorption as a mechanism for weight loss.

Health-related quality of life does not vary among patients seeking different surgical procedures to assist with weight loss

Background Improvement in quality of life (QOL) is 1 of the goals of bariatric procedures. We hypothesized that greater impairment of QOL would encourage the choice of more invasive surgical procedures. Our study was performed at a university hospital weight loss surgical center in the United States. Methods Patients qualifying for weight loss surgery, who at their surgical consultation had chosen their surgical option and signed an informed consent form, were asked to complete 3 QOL forms—the Medical Outcomes Study Short Form 36-item Health Survey, the Beck Depression Inventory, and the Impact of Weight on Quality of Life-Lite. Analysis of variance was used to compare the surgery types with the demographics, QOL, and depression. Results A total of 367 patients, 114 men (31.1%) and 253 women (68.75), completed the QOL forms at their surgical consultation. Of these 367 patients, 68.9% elected gastric bypass (GB), 15% chose biliopancreatic diversion/duodenal switch (BPD/DS), and 16.1% chose adjustable gastric banding (AGB). The mean patient age was 42.5 ± 10.7 years ( P = NS), with no differences in gender distribution. The body mass index was 51.9 kg/m 2 for the BPD/DS group, greater than that for the GB group (45.9 kg/m 2) or AGB group (44.3 kg/m 2; P < .0001). No significant differences were found in the Beck Depression Inventory score among the 3 groups (GB 14.6 ± 9.6, AGB 10.8 ± 8.2, and BPD/DS 13.5 ± 7.3). For the Short Form 36-item Health Survey, only the physical component score was different for the AGB group compared with the BPD/DS group (GB 49.2 ± 25.1, BPD/DS 42.8 ± 26.4, and AGB 52.3 ± 31.7; P = .05). For the Impact of Weight on Quality of Life-Lite, all differences were nonsignificant. The total score was 44.1 ± 20.7, 44.4 ± 21.1, and 52.2 ± 19.6 for the GB, BPD/DS, and AGB groups, respectively. Conclusion Patients requesting a weight loss procedure reported moderate to severe impairments in QOL and mood dysphoria compared with the community norms. However, the patients choosing from the 3 procedures studied scored similarly on the health-related QOL assessments.

Prevalence of Hyperoxaluria After Bariatric Surgery

Recent investigations have shown increased oxalate excretion in patients in whom kidney stones formed after contemporary bariatric surgery. We determined whether there is an increased prevalence of hyperoxaluria after such procedures performed in nonstone formers. A total of 58 nonstone forming adults who underwent laparoscopic Roux-en-Y (52) or a biliopancreatic diversion-duodenal switch procedure (6) collected 24-hour urine specimens 6 months or greater after bariatric surgery. Standard stone risk parameters were assessed. Comparisons were made with a group of healthy nonstone forming adults and stone formers in a commercial database. The bariatric group had a significantly higher mean urinary oxalate excretion compared to that in controls and stone formers (67.2 vs 34.1 and 37.0 mg per day, respectively, p <0.001). Mean oxalate excretion of patients who underwent a biliopancreatic diversion-duodenal switch procedure was higher than in the Roux-en-Y group (90 vs 62 mg per day, p <0.05). There was a significant correlation between urine oxalate excretion on the 2 collection days but some patients showed significant variability. Of the patients 74% showed hyperoxaluria in at least 1, 24-hour urine collection and 26% demonstrated profound hyperoxaluria, defined as oxalate excretion more than 100 mg per day, in at least 1 collection. This occurred in 3 of the 6 patients in the biliopancreatic diversion-duodenal switch group and in 12 of the 52 in the Roux-en-Y cohort. Hyperoxaluria was not uniformly expressed. There is a high prevalence of hyperoxaluria in patients without a history of kidney stones who undergo bariatric surgery. A significant proportion of these patients have profound hyperoxaluria, which is not uniformly expressed.

Inferior Vena Cava Syndrome and Morbid Obesity

A case is reported of inferior vena cava syndrome in a patient with extreme obesity (BMI: >70 kg/m(2)), treated at a public hospital. The inferior vena cava obstruction was diagnosed during an attempt at inferior vena cava filter percutaneous insertion, in prebariatric surgery period. The diagnosis occurred after a hepatic scintillography, and was confirmed with a femoral venography and celiac trunk arteriography. The patient underwent a biliopancreatic diversion-duodenal switch and has lost weight. A venography 7 months after the surgery did not show any inferior vena cava rechanneling evidence.

Parenteral Iron Replacement after Bariatric Surgery.

Background: Malabsorptive bariatric procedures such as Roux-en-Y gastric bypass (REY) and biliopancreatic diversion/duodenal switch (BPD/DS) expose the patient to significant metabolic effects, most commonly iron deficiency. Optimal replacement and monitoring strategies remain undetermined. Further, there are no data regarding parenteral iron replacement after bariatric surgery. We evaluated bariatric surgery patients who received parenteral iron replacement therapy at our hematology center.Methods: We performed a retrospective cohort analysis and reviewed the medical records of 165 patients who received parenteral iron from 5/04 to 6/07. 42 bariatric surgery patients were identified. The type of bariatric procedure and menstrual status of patients were compared. ANOVA, Chi-square and t-tests were used for statistical analysis.Results: The average age for the groups was similar; 40 years. There were only 2 men (4.76%) and 40 women, 32 (76%) of whom were of menstrual age and 8 (24%) were post-menopausal. 8 women were found to have other factors contributing to the anemia (7 with menorrhagia and 1 with celiac disease).Roux-en-Y gastric bypass (REY) versus biliopancreatic diversion/duodenal switch (BPD/DS) and menstruating women versus men and postmenopausal womenAll Patients n=42Roux-en-Y n=23Bilio-pancreatic diversion/Duodenal switch n=17p valueMenstrual women n=24Men and post-menopausal women n=10p valueMean hemoglobin gm/dl8.1(95% CI 7.738–8.638)8.57.50.02 *7.88.40.26Mean ferritin level ng/ml5.4(95% CI 3.3–7.5)6.23.90.334.137.770.2106Median time to parenteral iron therapy42.5months48 months43 months0.3237.5 months54 months0.008*Need for additional parenteral iron treatments24/42(57%)11/23(47%)13/17 (76.4%)0.001*15/24(62.5%)7/10(70%)0.062Number of anemia-related hospitalizations14/42 (33.3%)4/23 (17.39%)10/17(58.8%)0.01*12/24(50%)2/10(20%)0.00033**p value significant.Patients in the BPD/DS group had significantly lower hemoglobins (p=0.02) at the time of presentation, lower ferritin levels, and required subsequent parenteral iron treatments after initial resolution of anemia (p=0.001). The above parameters were not influenced by menstrual status. The number of anemia related hospitalizations was significantly higher in menstrual women (p=0.00033) and also in the BPD/DS group. Also, menstrual women required parenteral iron replacement earlier than men or postmenopausal women (p=0.008).Conclusion: A considerable number of patients develop severe, symptomatic iron deficiency anemia within 1–4 years after bariatric surgery and need parenteral iron replacement after oral iron therapy has failed. Malabsorption plays a significant role in the development of iron deficiency, and the greater the degree of malabsorption resulting from the bariatric procedure the more the likelihood of recurrence of iron deficiency. Menstrual women are at a higher risk due to continual iron losses and tend to require intravenous replacement earlier. Bariatric surgery patients who do not respond to oral iron therapy should be referred early for parenteral iron replacement, especially after malabsorptive procedures, particularly in women of child-bearing age. In order to maintain quality of life and prevent anemia related complications, close monitoring and early iron replacement are crucial, and the follow-up should be indefinite even after repletion of iron stores and resolution of anemia.

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There are procedures for the surgical treatment of severe obesity, one of which is the biliopancreatic diversion/duodenal switch (BPD/DS), a highly effective weight loss operation performed either open or laparoscopically. This is considered to be a very complex laparoscopic procedure. We have used a simplified laparoscopic gastric bypass procedure (2005 ASBS video) in > 2,000 cases, which has been reproduced in Latin America, Europe and Asia with similar results. As the BPD/DS may be more effective for super-obese patients, we have also developed a simplified and reproducible approach for this operation.